The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)
Has a history of alcohol abuse
Bathes three to four times a week
Has a history of diabetes mellitus
Becomes diaphoretic on warm days
is prescribed antidepressant
Has a history of a cerebrovascular accident CVA
Correct Answer : A,C,D,F
A. Has a history of alcohol abuse
Explanation: Alcohol can contribute to hypothermia as it causes vasodilation, leading to heat loss. It can impair the body's ability to regulate temperature.
B. Bathes three to four times a week
Explanation: While personal hygiene is important, the frequency of bathing alone may not be a direct risk factor for hypothermia. The overall environmental temperature and the individual's ability to regulate their body temperature are more critical considerations.
C. Has a history of diabetes mellitus
Explanation: Diabetes mellitus can increase the risk of hypothermia as it may affect circulation and peripheral nerve function. Impaired sensation and reduced blood flow can contribute to difficulty in maintaining body temperature.
D. Becomes diaphoretic on warm days
Explanation: Excessive sweating (diaphoresis) can contribute to the risk of hypothermia, as it leads to moisture loss from the skin, making it more challenging for the body to maintain a stable temperature.
E. Is prescribed antidepressant
Explanation: While certain medications, including some antidepressants, can affect thermoregulation, the prescription of an antidepressant alone does not necessarily indicate an increased risk of hypothermia. It is essential to consider the specific medication and its potential side effects.
F. Has a history of a cerebrovascular accident (CVA)
Explanation: Individuals with a history of a cerebrovascular accident may have impaired thermoregulation due to damage to the central nervous system. This can increase susceptibility to temperature extremes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Constipation is a common side effect of opioid medications like morphine. It is a priority to address because constipation can lead to discomfort, increased pain, and other complications. Preventive measures such as increased fiber intake, adequate hydration, and bowel regimen may be necessary.
B. Poor solid food intake and C. poor liquid intake are concerns, but they are secondary to the immediate issue of constipation. Adequate nutrition and hydration are important for overall recovery, but constipation can have more immediate and uncomfortable consequences.
D. Diarrhea is not a common side effect of morphine. In fact, constipation is a more common gastrointestinal side effect. If the patient were to experience diarrhea, it could be indicative of another issue or complication that needs to be addressed, but it is not the primary preventive care concern associated with morphine use.
Correct Answer is B
Explanation
A. Encouraging the client to use a cane when ambulating.
Explanation: Encouraging the use of a cane for ambulation can provide support and stability, aiding in fall prevention.
B. Keeping the side rails up on the client's bed at night.
Explanation: Keeping side rails up on the client's bed can pose a concern as it may increase the risk of entrapment and injury. Side rails can lead to accidental entrapment, and there is a potential for the client to try to climb over them, leading to falls or injuries. The use of side rails in older adults is a safety consideration that requires careful assessment and appropriate measures to prevent harm.
C. Keeping several low wattage night lights on in the evening.
Explanation: Using low wattage night lights is a good practice to enhance visibility and prevent tripping or stumbling in low-light conditions.
D. Installing wooden railings on the stairway to the bathroom.
Explanation: Installing railings on the stairway is a proactive measure to enhance safety and stability, especially in navigating stairs, and can contribute to fall prevention.
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